1679110464 NPI number — ANGIE SHAMMO

Table of content: ANGIE SHAMMO (NPI 1679110464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679110464 NPI number — ANGIE SHAMMO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAMMO
Provider First Name:
ANGIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679110464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 E 2ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESCONDIDO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92025-4212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-291-6700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 E 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESCONDIDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92025-4212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-291-6777
Provider Business Practice Location Address Fax Number:
760-737-7324
Provider Enumeration Date:
11/29/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  4704328368 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 95018797 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com